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Grand Rounds Purtscher’s Retinopathy

Grand Rounds Purtscher’s Retinopathy. Mark A. Ihnen, M.D. University of Louisville Department of Ophthalmology and Visual Sciences 4 /4/2014. Presentation. CC : “ I can’t make out faces with my right eye. ”

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Grand Rounds Purtscher’s Retinopathy

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  1. Grand RoundsPurtscher’s Retinopathy Mark A. Ihnen, M.D. University of Louisville Department of Ophthalmology and Visual Sciences 4/4/2014

  2. Presentation CC: “I can’t make out faces with my right eye.” HPI: 40 WM c/o blurred central vision OD after being struck by a car while changing a flat tire on an interstate off-ramp. The patient also sustained multiple rib fractures/pneumothorax and a laceration to the left ear. Transported to UL Emergency Department.

  3. Presentation POH: None PMH: None Meds:None Allergies: None

  4. Exam ODOS BCVA: 20/200 20/20 Pupils: 4  2 OU, no APD IOP: WNL OU EOM: Full OU Anterior Exam: Extensive subconjunctival hemorrhage OU, otherwise WNL

  5. Clinical Photos

  6. Dilated Fundus Exam at Bedside Fundus video OD demonstrating large peripapillary cotton-wool spots and superficial hemorrhages.

  7. Inpatient Clinical Course Patient’s left ear was surgically repaired Thoracostomy tube was removed, stable for discharge. Arranged to follow-up on the day of discharge in our Retina Clinic.

  8. Dilated Fundus Exam: Clinic Photos Color fundus photo of the right eye demonstrating multiple, large, peripapillary, cotton-wool spots and superficial hemorrhages. Note the intervening clear zones between each CWS sparing vessels.

  9. Dilated Fundus Exam: Clinic Photos Color fundus photo of the left eye: Normal.

  10. HVF 24-2 OU • OS OD HVF 24-2: Left eye: Full; Right Eye: Central scotoma.

  11. SD-OCT (OD) OCT image of right eye demonstrating elevation corresponding to large superficial cotton wool spot.

  12. SD-OCT (OS) OCT image of the left eye demonstrating normal foveal contour.

  13. FA of OD Mid phase FA of right eye demonstrating multiple areas of hypofluorescencecorresponding to large CWS.

  14. FA of OD Late phase FA of right eye demonstrating multiple areas of hypofluorescencecorresponding to large CWS with small amount of late leakage.

  15. FA of OS Mid phase FA of left eye within normal limits.

  16. Assessment and Plan 40 WM presenting with central scotoma OD and multiple peripapillary CWS following a thoracic compression injury. DDX: Purtscher’s Retinopathy Commotio Retinae Plan: IntravitrealKenalogInjection

  17. Clinical Course Patient initially refused IVKinjection and then reconsidered. Lost to follow-up.

  18. Purtscher’s Retinopathy • Introduction • First described by Dr. OthmarPurtscher(1852–1927)in 1910. • Originally observed in two severely traumatized patients with head injuries. • Fully described in a publication in 1912 by Dr. Purtscher. • True Purtscher's retinopathy, as first described, is always associated with a traumatic injury. • When there is a non-traumatic etiology the correct designation is Purtscher-like retinopathy. http://www.mrcophth.com/ophthalmologyhalloffame/purtscher.html

  19. Purtscher’s Retinopathy • Epidemiology • Incidence of 0.24 persons per million per year • Clinical Presentation • Patients present with decreased visual acuity, often sudden (usually within 48 hours) and severe (20/200 or worse) • History of compression injury to chest, head or long bone fracture (fat embolism syndrome) • Fundoscopic signs include peripapillary cotton wool spots and/or superficial hemorrhages in over 92% of cases. • Purtscherflecken are considered pathognomic, but only occur in 50% of cases. • Typically bilateral but many times unilateral.

  20. Purtscher-like Retinopathy • Purtscher-like retinopathy: not associated with trauma. • Associations include: • Acute pancreatitis • Indication of multiorgan failure and is often associated with a fatal outcome • Chronic renal failure • Autoimmune Disease • SLE, scleroderma, dermatomyositis, Sjogrensyndrome • Childbirth (amniotic fluid embolism) • Retrobulbar anesthesia • Valsalva maneuver

  21. Purtscher’s Retinopathy • Diagnosis • For trauma-related cases, the diagnosis is clinically apparent after fundus examination and no further workup is required. • However, cases without trauma or causative medical condition require a comprehensive medical evaluation in conjunction with an internist.

  22. Purtscher’s Retinopathy • Pathogenesis • Thought to be a result of injury-induced complement activation, which causes granulocyte aggregation and leukoembolization. • This process in turn occludes small arterioles such as those found in the peripapillary retina. • Treatment • No known effective treatment exists. • Anecdotal reports of limited success with high dose systemic corticosteroids.

  23. Purtscher’s Retinopathy • Prognosis • Although retinal whitening and hemorrhages slowly disappear over weeks to months, usually no significant recovery of vision occurs.

  24. Systematic Review • Mean visual acuity 20/200, range of 20/20 to LP. • Trauma and acute pancreatitis were the most frequent etiologies. • There was no statistically significant difference in VA improvement for patients treated with corticosteroids compared with observation. • Trauma and pancreatitis were associated with higher probability of visual improvement.

  25. Case report : 24 WF with post partum Purtscher- like retinopathy treated with sub-tenon triamcinolone Presenting VA 20/200 OD 5 week follow-up: VA 20/60

  26. Oral Indomethacin 25 mg/day for six weeks • 43 WM with Purtscher’s like retinopathy associated with valsalvamaneuver: Presenting VA CF OS 6 week follow–up VA 20/40 OS

  27. Thank You

  28. AtabayC, et al. Late visual recovery after intravenous methylprednisolone treatment of Purtscher's retinopathy. Ann Ophthalmol. 1993;25(9):330-333. Behrens-Baumann W, Scheurer G, Schroer H. Pathogenesis of Purtscher's retinopathy. Graefes Arch ClinExpOphthalmol. 1992;230(3):286-291 PurtscherO. Ber Deutsche OphthGes 1910;36:294-301. Jacob HS, Craddock PR, Hammerschmidt DE, Moldow CF. Complement-induced granulocyte aggregation: an unsuspected mechanism of disease. N Eng J Med. 1980;302:789-794. PurtscherO. Angiopathia retinae traumatica. Lymphorrhagien des Augengrunes. Albrecht Von Graefes Arch Ophthalmol. 1912;82:347-371. ScheurerG, Praetorius G, Damerau B, Behrens-Baumann W. Vascular occlusion of the retina: an experimental model. I. Leukocyte aggregates. Graefes Arch ClinExpOphthalmol. 1992; 230(3):275-280. MaassenJ, Oetting T. Purtscher's Retinopathy: 22-year-old male with vision loss after trauma. EyeRounds.org. May 18, 2005 BCSC: Retina and Vitreous: Purtscher’s Retinopathy: 105-106 Hsu J, Regillo CD. Distant Trauma with Posterior Segment Effects. Yanoff and Duker: Ophthalmolgoy 3rd ed. Ch 6.43: 751-752. References

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